Telemedicine involves the use of electronic communications
to enable healthcare providers at different locations to share individual
patient medical information for the purpose of improving patient
care. Providers may include primary care practitioners, specialists,
and/or subspecialists. The information may be used for diagnosis,
therapy, follow-up and/or education, and may include any of the
- Patient medical records
- Medical images
- Live two-way audio and video
- Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security
protocols to protect the confidentiality of patient identification
and imaging data and will include measures to safeguard the data
and to ensure its integrity against intentional or unintentional
Responsibility for the patient care should remain with the patient's
local clinician, if you have one, as does the patient's medical
- Improved access to medical care by enabling a patient to remain
in his/her local healthcare site (i.e. home) while the physician
consults and obtains test results at distant/other sites.
- More efficient medical evaluation and management.
- Obtaining expertise of a specialist.
As with any medical procedure, there are potential risks associated
with the use of telemedicine. These risks include, but may not be
- In rare cases, the consultant may determine that the transmitted
information is of inadequate quality, thus necessitating a face-to-face
meeting with the patient, or at least a rescheduled video consult;
- Delays in medical evaluation and treatment could occur due
to deficiencies or failures of the equipment;
- In very rare instances, security protocols could fail, causing
a breach of privacy of personal medical information;
- In rare cases, a lack of access to complete medical records
may result in adverse drug interactions or allergic reactions
or other judgment errors;
By checking the box associated with "Informed Consent",
You acknowledge that you understand and agree with the following:
- I understand that the laws that protect privacy and the confidentiality
of medical information also apply to telemedicine, and that
no information obtained in the use of telemedicine, which identifies
me, will be disclosed to researchers or other entities without
- I understand that I have the right to withhold or withdraw
my consent to the use of telemedicine in the course of my care
at any time, without affecting my right to future care or treatment.
- I understand the alternatives to telemedicine consultation
as they have been explained to me, and in choosing to participate
in a telemedicine consultation, I understand that some parts
of the exam involving physical tests may be conducted by individuals
at my location, or at a testing facility, at the direction of
the consulting healthcare provider.
- I understand that telemedicine may involve electronic communication
of my personal medical information to other medical practitioners
who may be located in other areas, including out of state.
- I understand that I may expect the anticipated benefits from
the use of telemedicine in my care, but that no results can
be guaranteed or assured.
- I understand that my healthcare information may be shared
with other individuals for scheduling and billing purposes.
Others may also be present during the consultation other than
my healthcare provider and consulting healthcare provider in
order to operate the video equipment. The above mentioned people
will all maintain confidentiality of the information obtained.
I further understand that I will be informed of their presence
in the consultation and thus will have the right to request
the following: (1) omit specific details of my medical history/physical
examination that are personally sensitive to me; (2) ask non-medical
personnel to leave the telemedicine examination room; and/or
(3) terminate the consultation at any time.
Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding
telemedicine, have discussed it with my physician or such assistants
as may be designated, and all of my questions have been answered
to my satisfaction.
I have read this document carefully, and understand the risks and
benefits of the teleconferencing consultation and have had my questions
regarding the procedure explained and I hereby give my informed
consent to participate in a telemedicine visit under the terms described
By checking the Box containing "INFORMED CONSENT FOR TELEMEDICINE
SERVICES" I hereby state that I have read, understood, and
agree to the terms of this document.